Patients receiving conventional hemodialysis have high hospitalisation rates, poor quality of life and survival compared to the general population. Many centres around the world are providing longer hours of hemodialysis - short daily hemodialysis and nocturnal hemodialysis - with a view to improving patient survival and quality of life. Studies have shown that nocturnal haemodiaysis is more effective than conventional hemodialysis in clearing most small, middle and larger molecule toxins and suggest nocturnal dialysis enhances patient survival and quality of life. Concerns include patient acceptance, vascular access related complications and increased cost. The purpose of this review is to examine the advantages and drawbacks of nocturnal dialysis, with a focus on applicability to India where the renal physician has to face cultural and economic barriers, erratic power supply and poor water quality.

The availability of hemodialysis machines equipped with online clearance monitoring (OCM) allows frequent assessment of dialysis efficiency and adequacy without the need for blood samples. Accurate estimation of the urea distribution volume (V) is required for Kt/V calculated from OCM to be consistent with conventional blood sample-based methods. A total of 35 patients were studied. Ionic dialysance was measured by conductivity monitoring. The second-generation Daugirdas formula was used to calculate the Kt/V single-pool (Kt/VD). Values of V to allow comparison between OCM and blood-based Kt/V were determined using Watson formula (VWa), bioimpedance spectroscopy (Vimp), and blood-based kinetic data (Vukm). Comparison of Kt/Vw ocm calculated by the ionic dialysance and Vw (Kt/Vw ocm) with Kt/VD shows that using VW leads to significant systematic underestimation of dialysis dose by 24%. Better agreement between Kt/V ocm and Kt/VD was observed when using Vimp and Vukm. Bio-impedancemetry and the indirect method using the second-generation Daugirdas equation are two methods of clinical interest for estimating V to ensure greater agreement between OCM and blood-based Kt/V.

Chronic kidney disease (CKD) is a growing problem worldwide. The disproportionate increase in the burden of cardiovascular disease in patients with CKD may be significantly contributed by nontraditional risk factors. Increased arterial stiffness has been recognized as an important player in contributing to this morbidity and mortality. The aim of this study was to report the effect of L-arginine on arterial stiffness and oxidative stress in patients with CKD. Thirty patients with stage II to IV CKD were administered 9 g of L- arginine per day orally for a period of 12 weeks. The parameters evaluated at baseline, at 8 weeks, and at the end of 12 weeks were serum nitric oxide (NO), carotid-femoral pulse wave velocity (cf PWV), and radial artery pulse wave analysis which included aortic augmentation pressure (AP), aortic augmentation index (AIx), aortic augmentation index at heart rate of 75 bpm, subendocardial viability ratio, radial pressures, and central aortic pressure. Serum levels of NO and malondialdehyde (MDA) were estimated at baseline and at the end of 12 weeks. The control group was composed of age- and sex-matched healthy individuals. Twenty-five patients completed the study. Two patients were lost to follow-up; three patients developed adverse events and were excluded. Baseline NO levels were low (13.55 ± 7.49 μM/L) in all the subjects. Administration of L-arginine resulted in improvement in the carotid-radial PWV (m/s) (10.08 ± 1.72 at baseline to 8.56 ± 1.16 by 12 weeks; P < 0.001), cf PWV (m/s) (13.06 ± 2.65 at baseline to 10.62 ± 1.93 at 12 weeks; P < 0.001), Aortic Augmentation Index (%) (32 ± 10.34 at baseline to 17.84 ± 8.05 at 12 weeks; P < 0.001), aortic augmentation pressure (mm of Hg) (14.03 ± 6.53 at baseline to 7.12 ± 3.85 at 12 weeks; P < 0.001), and NO (μM/L) (13.55 ± 7.49 at baseline to 30.22 ± 9.8 at 12 weeks; P < 0.001). There was no significant change in the levels of MDA (nanomol/ml) (20.0 ± 10.14 at baseline and 19.16 ± 9.36 at 12 weeks; P = ns). In conclusion, PWV, an indicator of arterial stiffness, is greatly increased even in the early stages of CKD. Supplementation of L-arginine is a safe, well-tolerated, and effective way of improving endothelial dysfunction in patients with CKD.

Human cytomegalovirus (HCMV) is an important cause of morbidity and mortality in immunosuppressed transplant recipients. Isolation of HCMV from peripheral blood leukocytes (PBLs) is considered a reliable marker of disseminated HCMV infection. HCMV pp65 antigenemia is widely used for monitoring CMV infection and guiding preemptive therapy. The aim of this study was to compare pp65 antigenemia with culture technique for detection of HCMV in PBLs among kidney transplant patients and also to determine the threshold value of significant pp65 antigenemiat. Fifty-one peripheral blood samples from post-renal transplant patients collected during August 2009 to March 2011 were processed for pp65 antigenemia assay. These were also tested for isolation of the virus by inoculation into human corneal fibroblast cells. The results of pp65 antigenemia and culture were compared to determine the clinical significance of pp65 antigenemia. HCMV was isolated in 21 cases. On comparing the pp65 antigenemia results with that of the viral isolation, a mean of 23 cells was determined to yield a positive isolation of HCMV. The values of pp65 antigenemia and isolation results were correlated (paired t-test, P = 0.0029). A pp65 count of 23 and above was considered significant in our clinical settings since we found that these clinical specimens yield positive culture result.

Systemic lupus erythematosus (SLE) is a prototype autoimmune disease, characterized by immune complex formation and systemic inflammation. Complement components such as C1q and mannose-binding lectin (MBL) play an important role in the clearance of immune complexes. Anti-C1q antibodies are associated with lupus nephritis and reduced levels of the complement components. The objective of this study was to detect anti-C1q antibodies in SLE patients and to evaluate their association with the complement components. Sixty SLE patients were included, of whom 75% had lupus nephritis (LN) and 25% were without renal manifestations (non-LN). The disease activity was assessed at the time of evaluation by the systemic lupus erythematosus disease activity index (SLEDAI). Anti-C1q antibodies, circulating immune complexes, and serum MBL levels were detected by enzyme-linked immunosorbent assay. The anti-C1q antibody prevalence was 58.3%. The LN patients showed 60% anti-C1q positivity with a higher percentage in membranoproliferative glomerulonephritis patients (51.9%). Anti-dsDNA positivity was slightly higher among the anti-C1q positives than in the anti-C1q negatives (65.7% vs. 60%). A higher percentage of reduced C3 and C4 levels was noted among the anti-C1q positives. The LN patients showed a higher percentage of low MBL levels among anti-C1q negatives than in the anti-C1q positives (61.1% vs. 55.6%). Non-LN patients showed a higher percentage of low MBL levels among anti-C1q positives than among anti-C1q negatives (87.5% vs. 57.1%). Anti-C1q antibodies were found in both LN and non-LN patients, but there was no correlation with the clinical severity of the disease.

Nondiabetic renal disease (NDRD) is seen as a cause of proteinuria and renal failure in type 2 diabetes mellitus (DM). The clinical differences between NDRD and diabetic glomerulosclerosis (DGS) are not clear. This study was done to find the spectrum of NDRD in type 2 DM patients and differences in clinical profile between NDRD and DGS patients. Data of patients with type 2 DM who underwent renal biopsy in this institute from 1990 to 2008 were analyzed retrospectively. Patients were categorized as isolated NDRD, NDRD with DGS, and isolated DGS. A total of 75 patients were included. Mean age was 45 ± 10.2 years, male to female ratio was 3.1 : 1, median duration of DM was 12 months (range, 1 year-15 years), proteinuria was 4.2 ± 3.4 g/day, and serum creatinine was 4.3 ± 3.9 mg/dl. Hypertension was observed in 63 (84%) cases and microscopic hematuria in 24 (32%) cases. Nephrotic syndrome (38.7%) was the commonest clinical presentation. Forty-eight (64%) cases had NDRD and 27 (36%) had DGS. The commonest NDRD was minimal change disease (12.5%). Three (6.3%) patients had lupus nephritis. Tubulointerstitial nephritis has been observed in 10.4% patients. No significant differences between NDRD and DGS patients were found except hypertension which was significantly high in the DGS group. Acute kidney injury and nephritic syndrome were not observed in the DGS group. In conclusion, the incidence of biopsy-proven NDRD in type 2 DM in this study was high. Kidney biopsy aided in the detection of NDRD in clinically suspected patients.

Acute kidney injury (AKI) is common in hospitalized patients and is an important cause of mortality. This is a descriptive study of AKI in patients from Himachal Pradesh, India, located in Western Himalayan region. Over a period of 1 year, 102 patients with clinical and laboratory evidence of azotemia were included. Out of 102 patients, 84.3% had community acquired AKI and 15.7% had hospital acquired AKI. Medical causes were leading contributors (85.3%), with septicemia being the main factor (33.3%). Multiorgan failure was present in 59.8% patients. The overall mortality was 29.2%, and community acquired AKI was associated with higher mortality as compared to hospital-acquired AKI (22.5% vs 6.7%). AKI is still common in community and associated with high mortality. Septicemia, volume depletion and nephrotoxins were the leading cause of AKI in our study. Our study highlights the presence of hypotension, multiorgan failure and oliguria with mortality. Community-acquired AKI had higher mortality than hospital-acquired AKI.

Linezolid, a member of oxazolidinone antibiotic class, is a relatively well-tolerated drug with few side effects. It is active against gram-positive cocci, including multidrug resistant staphylococci and enterococci. We report a case of a 54-year-old diabetic male with alcoholic cirrhosis admitted in intensive care unit with altered sensorium. He was diagnosed as a case of hepatic failure secondary to hepatitis E infection and enterococcal urosepsis. He was started on linezolid based on the urine culture sensitivity report. On day three of linezolid treatment, he developed severe pruritus, macular rash, eosinophilia, and renal dysfunction. Renal biopsy showed acute tubulointerstitial nephritis. Renal functions improved on discontinuation of linezolid and short course of steroid therapy.

Membranous nephropathy is a common glomerular disease. We report a 50-year-old man with a history of membranous nephropathy in remission, who presented with acute kidney injury, proteinuria, hematuria, and hypertension. He also had a high anti-glomerular basement membrane (anti-GBM) antibody titer and crescent transformation of primary pathology. The kidney functions deteriorated rapidly despite aggressive therapy with cyclophosphamide, methylprednisolone, and plasmapheresis.

Extended spectrum beta lactamase (ESBL) producing bacteria that are capable of hydrolyzing even third generation cephalosporin are emerging as a potent threat. We report a seven-year-old child on continuous ambulatory peritoneal dialysis, who developed ESBL producing Klebsiella pneumoniae peritonitis. The bacterium was resistant to the usual intraperitoneal antibiotics. We successfully treated the child with intravenous meropenem along with oral cotrimoxazole. The case highlights the menace of ESBL peritonitis, as also a need for the development of guidelines for such a scenario, which is becoming increasingly common in India.

Rapidly progressive glomerulonephritis in a patient with renal amyloidosis: Case report and review of the literature

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YJ Anupama, M VankalakuntiDOI:10.4103/0971-4065.103931 PMID:23326051

Renal amyloidosis is characterized by progressive deposition of extracellular material, most commonly in the glomeruli. Most often, patients present with nephrotic range proteinuria and the disease progresses gradually to renal failure. Rapid worsening of renal functions is rare. We report a case of crescentic glomerulonephritis superimposed on amyloidosis, clinically presenting as rapidly progressive renal failure, and present a review of the literature.

Hernia is one of the commonest complications of peritoneal dialysis. It is recommended that patients undergo surgical repair of hernias immediately after the diagnosis. We report a patient on continuous ambulatory peritoneal dialysis presenting with strangulated umbilical hernia. He underwent resection of the gangrenous ileum and end-to-end anastomosis. He was shifted to hemodialysis on second postoperative day and was continued on hemodialysis for 2 weeks. In the third week, he was initiated on low volume PD exchanges and by the fourth week, he returned to normal CAPD exchanges.

Isoniazid and rifampicin are used for management of tuberculosis. Acute poisoning due to isoniazid overdose is associated with repetitive generalized tonic-clonic seizures and severe metabolic acidosis. In toxic doses, rifampicin is known to produce hepatic, renal, hematological disorders, and convulsions. Sometimes, it may produce red man syndrome. We report a case of fatal poisoning with isoniazid and rifampicin. The case was characterized by late presentation, lactic acidosis, and renal failure.

In this report, we discuss a case of a 51-year-old African renal transplant who presented with metastatic Kaposi sarcoma 1 year after transplant. The Kaposi sarcoma was treated with a switch of immunosuppressants and chemotherapy. Six years after transplant, he presented with chronic allograft nephropathy, allograft tuberculosis, BK viremia, and was diagnosed to have contracted HIV infection.